Remote Radiology

Typically, when neurologists refer patients to Sumir S. Patel, MD, MBA, for image-guided neuroradiology procedures, they place an order to schedule the appointment. But Patel realized that when patients arrived at the hospital, they often had limited information and a lot of anxiety about the procedure.

“I’d meet patients for the first time on the day of their procedure, and they’d have a lot of questions because the doctor who ordered the procedure was not well-versed in the details of it,” says Patel, director of the Division of Community Radiology Specialists at Emory University School of Medicine. “They’d have questions about the benefits, the risks, the recovery time and the follow up.”

After years of having these conversations right before complex procedures, which was nerve-wracking for patients and time-draining for Patel’s schedule, he realized that last-minute discussions weren’t ideal.

“I always felt like this was suboptimal patient care because they’re coming into the procedure anxious, not knowing what to expect,” he says. “It’s also not great from a practice efficiency or time management standpoint because you’re having a lengthy conversation with the patient that’s necessary, but not necessarily ideal to have at that moment. I knew we could provide much better value to our patients and our referring providers by offering those discussions at a more suitable time and becoming more of a consultative service prior to the procedure.”

However, logistical hurdles clouded the idea of setting up a physical clinic space and bringing in patients for an additional consultation — especially since many of them had to drive several hours to reach the Atlanta-based hospital.

Sumir S. Patel, MD, MBA, started scheduling telehealth visits in the spring of 2020 to prepare patients for complex image-guided procedures.

Then, a silver-lining solution suddenly emerged in the spring of 2020 when the Center for Medicare and Medicaid Services (CMS) expanded its coverage for telehealth care as part of the COVID-19 public health emergency. CMS began to cover telehealth visits — defined as real-time communication between providers and patients to deliver care through an interactive telecommunications system — at the same rate as in-person appointments, and many state Medicaid programs and private insurers followed suit.¹

These relaxed regulations opened the door to virtual visits across specialties, allowing doctors like Patel more flexibility to remotely provide consultative medical services to patients during the pandemic. Taking advantage of the regulatory opportunity, Patel started scheduling telehealth visits to prepare patients for complex image-guided procedures.

Partnering with Referring Providers

Patel’s telehealth initiative started with patients being referred for myelograms and epidural blood patches to diagnose and treat spontaneous intracranial hypotension (SIH). He realized that “the referrers didn’t know quite what to do with them,” he says, because this often-misdiagnosed condition brings variable presentations, causes and imaging options.²

“Referrers would call to discuss these cases with me to determine the next steps,” Patel says. “Instead of just telling them which procedure to order, I asked if I could see the patient and order the procedures myself based on their history and prior imaging.”

As other referring clinicians reached out to him regarding procedures “more complex than simple lumbar punctures or routine myelograms,” such as epidural steroid injections and synovial cyst fenestration, Patel offered to consult with patients directly.

“Instead of placing an order for the procedure, I have referrers place an order for a consult with me,” Patel says. “Then I schedule a telehealth visit with the patient and discuss all the questions they have about the recommended procedure, the risks, the benefits and possible other options. Then we formulate a plan together, and I place the order for the procedure or follow-up imaging that the patient needs.”

Kathie Brown, PA-C, a physician assistant and headache specialist at PANDA Neurology and Atlanta Headache Specialists, refers patients to Patel who have low-pressure headaches from cerebrospinal fluid (CSF) leaks.

“When patients ask me, ‘How long does it take? How much does it hurt? What if this happens?’ I’m able to say, ‘I don’t do the procedures; I don’t know. But Dr. Patel will answer all your questions when you talk to him,’” Brown says. “I trust his judgment, so if he wants to do a myelogram instead of blood patch, I don’t want to choose that for him.”

Referring providers are relieved to let Patel step in and consult with patients. Instead of placing orders for specific studies, they can rely on his imaging expertise to recommend and order the most appropriate procedure for each patient. Whether it’s an epidural steroid injection guided by X-ray (XR), interventional radiology (IR), or computed tomography (CT), “the referring providers don’t care which modality we use,” Patel says. “They just want to help the patient.”

Most of Patel’s referring physicians now send patients directly to him instead of ordering certain image-guided procedures, so he can consult with patients before placing the order. Occasionally, doctors who aren’t aware of the telehealth clinic will schedule one of these procedures without an initial consultation. In those cases, Patel reaches out to the patient to set up a telehealth visit ahead of the scheduled procedure and notifies the ordering provider.

“The benefit for referring physicians is that they don’t have to worry about what kind of imaging equipment we’re going to use or what the specific name of the order is,” Patel says. “They just know that once they refer the patient to me, everything will be taken care of, and that’s all they have to worry about.

Consulting with Patients Virtually

Telehealth regulations vary from state to state, but in accordance with Georgia’s requirements, Patel must begin every telehealth visit by verifying that the patient is physically located in Georgia and obtaining the individual’s consent to proceed with the telehealth visit.

Once location and consent are confirmed, everyone on the videoconference introduces themselves. Oftentimes, there are more people on the call than just Patel and the patient. “The great part about telehealth is that they can bring their family members from all over the world,” he says. “They can share the link with anyone they want to invite.”

Another advantage is that virtual visits give patients the opportunity to ask questions from the comfort of their own home, he says, instead of racing through their questions minutes before the procedure.

“The telehealth visit is very informative and reassuring for patients,” Brown says. “It gives them some peace of mind.”

After Patel asks several detailed questions about the patient’s symptoms and history, he reviews the individual’s prior imaging studies via screen-share during the telehealth visit to illustrate the pathology and even show the projected path of the needle during the upcoming procedure. The interactive video format and screen-sharing tools enable Patel to discuss findings and recommendations with “a level of detail that referring providers just can’t,” he says. “The patients really appreciate that, because when they come in for the procedure, they know exactly what to expect. That’s huge for reducing anxiety.”

By facilitating patient engagement, this telehealth clinic also “enables shared decision-making that empowers patients to make more educated decisions about their care,” says Sabiha Raoof, MD, FACR, FCCP, co-chair of the ACR Commission on Patient- and Family-Centered Care (PFCC) Quality Experience Committee. She sees Patel’s telehealth clinic as an effective model that other radiologists can easily replicate to enhance patient care.

Sabiha Raoof, MD, FACR, FCCP, co-chair of the ACR Commission on Patient- and Family-Centered Care (PFCC) Quality Experience Committee, sees Patel’s telehealth clinic as an effective and replicable model.

“Setting up a physical clinic can be complex, but everybody has the capability to do what Dr. Patel is doing with virtual visits,” says Raoof, chief medical officer, patient safety officer and chair of the radiology departments at MediSys Health Network’s Jamaica and Flushing Hospital Medical Centers in the Queens borough of New York City. “Telehealth makes it easier to engage patients, especially those who don’t have time to come to the hospital for a pre-visit, then the actual procedure, and then post-procedure follow-up. They’re more amenable to telehealth visits, which they can do from anywhere without taking a day off work.”

Forging a Novel Role

Even before the public health emergency opened the door to virtual appointments, some IR and nuclear medicine departments established physical clinics to prepare patients for complex procedures. Emory established a nuclear medicine clinic several years prior to the pandemic, around 2015.

“Pre-COVID, this was in-person. Then, when COVID happened, the nuclear medicine clinic switched completely to telemed to reduce patients coming in, and IR followed a similar model,” says Shahein H. Tajmir, MD, a nuclear medicine physician who worked with Patel at Emory before becoming director of nuclear medicine IT at Massachusetts General Hospital in late 2022. “I’ve noticed more and more IR docs scheduling virtual visits as the initial evaluation when they get a referral now.”

However, outside of IR and nuclear medicine, it’s relatively rare for radiologists to offer these consultations. While basic diagnostic scans and simple neuroradiology procedures — like lumbar punctures or shoulder pain injections — are straightforward enough for ordering physicians to explain to patients, Patel doesn’t expect referring clinicians to know every detail about complex neuroradiology procedures.

“That’s where radiologists can add value by taking the reins to direct patient care,” Patel says. “For non-IR docs who do complex image-guided procedures, telehealth presents an opportunity to assuage the patient’s anxiety and provide a quality service for them as well as our referring providers. That’s where the value lies, is increasing the scope of radiologists to do telehealth consultations with patients instead of relegating it just to IR.”

Although it’s not unprecedented for radiologists to offer telehealth clinics, one major technical challenge is that diagnostic radiologists don’t always have full patient-facing privileges in electronic medical record (EMR) systems.

“There are a lot of IT hurdles due to us historically not being considered patient-facing specialties,” Tajmir says. “Some hospitals set up the EMR so that radiologists can’t place notes in charts or order labs and exams, so you need to make sure that your permissions are set up as if you’re a patient-facing doctor. IR has fought this battle before, which paved the way for procedural radiology.”

Although Emory had already given radiologists the ability to place orders and make notes in the EMR, Patel’s provider status in the system had to be changed from diagnostic to interventional radiologist. “Only then could they build a clinic schedule for me to meet with patients,” he explains.

Handling the Logistics

As common as remote videoconferencing software was during the pandemic, Patel still faced technical barriers in setting up his telehealth clinic.

Early on, Patel realized he was spending a lot of time “training” patients to use Zoom by pointing out where the unmute and video buttons appeared on the screen. Other physicians across the enterprise felt the same frustrations, prompting Emory to develop instructions to help patients adjust their settings prior to telehealth appointments. Patel also created his own document for patients explaining how to upload imaging exams prior to the visit if they were coming from outside of Emory Healthcare Network.

Although these checklists helped patients prepare, coordinating the telehealth visits still involved administrative preparation including scheduling Zoom meetings, sending out links and pre-appointment instructions and registering patients — especially since Patel was operating solo. Then, in October 2022, Emory adopted Epic software as its EMR, gaining access to an integrated videoconferencing platform that streamlined the technical workflow.

Patel created a document for patients explaining how to upload imaging exams prior to the visit if they were coming from outside of Emory Healthcare Network, which is now housed on the Emory Healthcare website.

“It’s even easier now because the patients get a link through their MyChart account, as opposed to digging through emails to find a Zoom meeting link and password,” Patel says. “I’ve had zero technological issues since our new system went live.”

Seamless EMR integration is key to a successful telehealth clinic, Tajmir agrees. “From the patient’s perspective and ours, you want everything to be as smooth as possible,” he says. “Ultimately, telemed comes at the expense of reading room time, so you want to minimize downtime as much as possible so you can get back to reading studies.”

Even with an integrated platform, telehealth consultations add time demands to radiologists’ already busy schedules, so scheduling these visits can be a juggling act. “Most of my day is generally interpreting images, so I can pepper in 30-minute visits here and there during those days,” Patel says. “I make up for that by staying a little late or having colleagues help out with reading that day.”

Patel’s telehealth visits average about 30 minutes each. He also allots 15 minutes after each appointment to add notes to the patient’s chart, order any necessary exams and schedule procedures. When he started offering telehealth visits in the spring of 2020, he met with one or two patients a month. As the program gained traction, now averaging two telehealth visits a week, he realized he needed help handling the logistics.

“As the only non-IR doc doing telehealth visits, the support was minimal. I had to find somebody to help register and schedule the patients,” Patel says. “We were able to find some administrative help by allocating someone who was already in the department. Without that support, this initiative would be dead in the water.”

Traditional IR and nuclear medicine clinics, including Emory’s, often employ nurse navigators to handle these administrative tasks — freeing up radiologists to focus on patients. This support staff is the lynchpin of a successful telehealth initiative.

“Just because it’s virtual doesn’t mean you can skimp on the staff,” Tajmir says. “The logistics may be too much for one radiologist to bear, unless you invest in a support staff to handle some of the tedious backend work.”

Adding Value

Traditionally, when patients arrived for neuroradiology procedures, they wouldn’t meet Patel until he entered the exam room in full procedural gear, with most of his face hidden under a surgical mask and cap. Most patients didn’t understand his role as a radiologist or realize how his imaging expertise impacted their care. But after interacting with Patel via telehealth, patients’ perceptions changed noticeably when they saw him on the day of the procedure.

“When they see me now, they’re seeing a familiar face instead of some random person they’re meeting for the first time, and that helps relieve their anxiety,” he says. “Before, when I would walk into the room, they’d look at me with skepticism, but it’s very different if you’ve already met before. When you consult with patients, you’re not just a name on the bottom of the report or a stranger dressed up in procedural garb. They know you.”

That sense of familiarity goes a long way to reduce patient anxiety before a procedure. “It definitely boosts their confidence to have a pre-existing relationship with the radiologist, rather than seeing a guy behind a surgical mask,” Brown says.

Telehealth consults elevate the perception of radiology even further by establishing radiologists as engaged members of the care team rather than just proceduralists.
“In the old days, patients would meet the proceduralist on the day of the procedure,” Tajmir says. “Now, you meet the patients, assess their needs, discuss their options, determine the best intervention and then bring them back for the procedure. That establishes us as a decision-maker rather than just an executor. This is where the telemed clinic has a role in radiology.”

By taking a more active, consultative role in patient care, radiologists demonstrate their value to referring providers as well.

“It’s a different set of expectations when referring providers don’t view us as just technicians, but give us some decision-making proxy,” Tajmir says. “You earn that respect from referring providers by seeing the patients beforehand and actually assessing their needs instead of just doing whatever the doctor orders. If we never see the patient in the clinic setting, then referrers never think of us as physician peers. They just think of us as the help. You have to build respect from your referrers before they respect you as a clinical decision-maker. Once you do, it changes the framing entirely.”

Exploring the Future of Telehealth

During the COVID public health emergency, relaxed telehealth regulations greatly expanded patients’ access to virtual services like Patel’s clinic, which he bills as evaluation and management (E/M) visits under the Medicare Physician Fee Schedule. Telehealth accounted for less than 1% of all Medicare fee-for-service outpatient visits in the U.S. in 2019 and rapidly grew to 46% of all visits by April 2020.³

But what does the future hold for telehealth, especially after the public health emergency expires on May 11, 2023?⁴

Several telehealth flexibilities allowed during the pandemic will expire right along with it. For example, during COVID, the U.S. Department of Health and Human Services (HHS) waived penalties for HIPPA violations against healthcare providers “that serve patients in good faith through everyday communications technologies,” like Skype or FaceTime. This waiver is set to expire along with the public health emergency in May.⁵

The Consolidated Appropriations Act of 2023 extended other flexibilities until the end of 2024, including Medicare coverage for telehealth services. While many private insurance companies are expected to follow Medicare’s lead and continue paying for telehealth services until then, some carriers are already cutting coverage.⁶

“In Georgia, the insurance carriers seem to be paying for telehealth visits as if they were in-person visits,” Tajmir says. “But now that I’m working in Massachusetts, I’ve seen at least two major carriers make decisions to cut their coverage for virtual visits by 20% compared to in-person visits. There’s a movement to reduce telehealth payments, and that bodes poorly for these clinics.”

However, Patel and Tajmir agree that the demand for telehealth will outlast the public health emergency, and the benefits it brings to patients and providers will ultimately outweigh the alternatives of meeting patients in-person or not consulting with them at all. In certain cases, telehealth is an indispensable tool empowering radiologists to engage in patient care.

“As radiologists, we really need to be out there showing our patients and our referring clinicians the value that we add to patient care,” Raoof says. “Some of us just like to sit in our dark rooms and read, and as a result, the patients really don’t know what radiologists do. By engaging patients, we show them and their referring physicians how we are involved in care and how much value we can add.”

Patel’s goal is making these telehealth consults so pervasive — not just in Emory’s neuroradiology department, but across procedural radiology practices everywhere — that patients expect it.

“I don’t think patients quite realize how unorthodox it is for a radiologist to offer telehealth visits, because now I’m just like any other doctor they see on telehealth,” Patel says. “If you grow to the point that it becomes commonplace for patients to have telehealth visits with their radiologist, that is success. Then we are no longer the docs in the back room; we are front and center with patient care.”

For More Information:

The Telehealth Initiative  — a partnership between The Physicians Foundation, American Medical Association, Florida Medical Association, Massachusetts Medical Society and Texas Medical Association — offers resources to help physicians and care teams implement telehealth. These resources, and others, include:

• AMA Telehealth Quick Guide 
•  AMA Digital Health Implementation Playbook 
•  Telemedicine During the COVID-19 Public Health Emergency — Frequently Asked Questions  
•  HHS Telehealth Resources for Providers